Vivid
Service Intake Form
"
*
" indicates required fields
Details of person completing this form:
Name
*
First
Last
Phone
*
Email
Relationship to client
*
Preferred method of contact
*
Email
Phone
Participant Information
Are you an existing Vivid client?
No
Yes
Name
*
First
Last
Email
*
Date of Birth
*
DD slash MM slash YYYY
Location
*
Loddon (Echuca/Moama, Kyabram and surrounds)
Mallee (Swan Hill, Kerang and surrounds)
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
Preferred contact method/person
*
Diagnosed Disability/Medical Condition
*
Detail the supports you are seeking:
Group Based Programs
Yes
Program Streams (Adventure & Recreation, Culture & Arts, Life Skills, Work Skills, Communication & Technology, Healthy Living, UPbicycle Bike Restoration) HUB Shed, HUB Bloom, HUB Seed to Plate, HUB Seed to Sell, HUB Sweet Life. Preferred days (Monday, Tuesday, Wednesday, Thursday, Friday)
Please Select Program Streams
Adventure & Recreation
Culture & Arts
Life Skills
Work Skills
Communication & Technology
Healthy Living
UPbicycle Bike Restoration
HUB
Please Select HUB Stream
HUB Shed
HUB Bloom
HUB Seed to Plate
HUB Seed to Sell
HUB Sweet Life
Is transport required?
Yes
Preferred Days
Monday
Tuesday
Wednesday
Thursday
Friday
Individualised Supports
Yes
1:1 Supports, In Home Supports, Community Access (days and hours per week)
Please Select the Type of Individualised Support
1:1 Supports
In Home Supports
Community Access
Preferred Days
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Time
*
Hours
:
Minutes
AM
PM
AM/PM
Employment
Yes
Employment – School Leaver Employment Supports (SLES), Supported Employment (Mon-Fridays and hours per week), Supports in Employment (days and hours per week).
Please Select the Type of Employment Support
School Leaver Employment Supports (SLES)
Supported Employment
Supports in Employment
Preferred Days
Monday
Tuesday
Wednesday
Thursday
Friday
Living Options
Yes
Living Options
Supported Independent Living
Supported Accommodation
Other
Support worker preferences (if any)
NDIS Goals
My NDIS goals are
*
Support needs
Do you have a Medical Management Plan?
*
Yes
No
Medical Management Plan type
*
Tick all that apply.
Management Plan – Asthma
Management Plan – Diabetes
Management Plan – Dysphagia
Management Plan – Epilepsy
Management Plan – Mental Health
Management Plan – Other
Medication
*
Yes
No
Medication - Details
*
A management plan must be provided prior to formal offer/commencement.
Medication to be administered by Vivid
*
Yes
No
Medication to be administered by Vivid - Details
*
Medication to be administered by Self
*
Yes
No
Medication to be administered by Self - Details
*
Behaviour Support Plan
*
Yes
No
Behaviour Support Plan - Details
*
A management plan must be provided prior to formal offer/commencement.
Behaviours (Are there any physical or sexualised behaviours)
*
Yes
No
Behaviours - Details
*
A management plan must be provided prior to formal offer/commencement.
Any court orders/legal intervention we need to be aware of
*
Yes
No
Court orders/legal intervention - Details
*
A management plan must be provided prior to formal offer/commencement.
Funding Details/Billing
Funding source
*
NDIS
Brokerage/TAC
Self Funded
NDIS Number
*
Plan Nominee
*
Plan Start Date
*
DD slash MM slash YYYY
Plan End Date
*
DD slash MM slash YYYY
Upload NDIS Plan
Max. file size: 100 MB.
Management Type
*
NDIA
Self-Managed
Plan Managed
Tick all appropriate
Name of Plan Manager
Plan Manager Phone
Plan Manager Email
Support Coordinated
*
Yes
No
Support Name
*
Name
Support Email
*
Support Phone
*
Other Information
Case Manager Name
*
First
Last
Case Manager Email
*
Case Manager Phone
*
Additional Information
Comments/Info
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